Bill seeks to limit higher prices for specialty drugs

AUGUSTA, Maine — A new trend in health insurance has Victoria Kuhn worried she won’t be able to afford her son’s hemophilia injections.

If a bill now before Maine legislators fails to pass, her 7-year-old son’s medication could leave her and her husband footing an annual bill of $30,000, she said.

“I don’t know what we would do as a family,” Kuhn said.

In an effort to control spending, some insurers are passing along more costs for expensive drugs to consumers and employers. Medications for arthritis, cancer, multiple sclerosis and other conditions now often carry an out-of-pocket “co-insurance” charge, rather than a flat co-payment, that can run into the thousands of dollars.

Three days a week, Kuhn and her husband inject William with his “Superman juice,” a drug that prevents painful bleeding episodes and allows him to ride his bike, ski and swim like other kids, she said. The drug costs $100,000 a year, $3,000 of which the family pays for out of pocket.

But if their health plan leaves them picking up more of the tab for the specialty medication, the cost could skyrocket, she said. Kuhn and her husband would be forced to put the brakes on the growth of their small Portland marketing company and risk jeopardizing their son’s health by missing his injections, she said.

A bill sponsored by Rep. Stacey Fitts, R-Pittsfield, would prevent private insurers from charging Maine consumers more for specialty drugs than for other medications. The bill, LD 1691, would not apply to government-subsidized plans or self-funded health insurance used by some employers.

So-called “tiers” have long been used by insurers and employers to set varying rates for different types of prescription drugs. But the practice took off when Medicare began allowing tiers for certain costly specialty drugs, and the private insurance market soon followed.

The percent of employers offering plans with specialty drug tiers grew 25 percent last year, according to the Pharmacy Benefit Management Institute. In 2010, New York passed legislation outlawing specialty drug tiers and a number of other states are considering similar measures.

Insurers argue the practice saves money by steering patients to cheaper generic drugs, but health advocates say generics aren’t available for many specialty medications and say tiers can discourage patients from taking their medications.

“When employers use these so-called tiers of drugs, it’s really one of the levers they use to control costs,” said Chris Dugan, a spokesman for Anthem in Maine, which opposes the bill.

Mandated benefits, such as those spelled out under LD 1691, ultimately drive up premiums for all policyholders, he said.

“While we think the legislation is well intended, it’s hard for our customers to absorb these types of costs going forward,” Dugan said.

The bill is also premature, as provisions of the federal health reform law governing drug benefits are still being ironed out, he said.

The Legislature’s Insurance and Financial Services Committee is scheduled to take up LD 1691 next week.